Cardioverter Defibrillator Research Articles

159 Ghost of Infected Leads: A New Criterion Associated with the Diagnosis of Cardiac Device-Related Infective Endocarditis

Objectives We sought to determine the incidence, diagnostic value and outcome of intracardiac masses observed by echocardiography after device removal. We hypothesized that these “ghosts” of leads could be associated with the diagnosis of cardiac device-related infective endocarditis (CDRIE). Background Echocardiographic appearance of residual floating masses in the right atrium has recently been described after removal of permanent pacemakers (PPM) and implantable cardiovertor defibrillators (ICD). Methods The preoperative clinical, microbiological and echocardiographic conditions, the indication and the type of removal technique were analysed in a retrospective cohort including all consecutive patients who underwent percutaneous lead removal at our institution. Three groups were formed according to the final diagnosis: CDRIE, local device infection (LDI), and non-infective indications. Incidence of ghosts was compared between the three groups. All predefined clinical and technical factors were studied for their association with ghosts. All patients with ghost were followed after hospitalization. Results Two hundred and twelve patients underwent lead removal. Ghosts were observed in 17 patients (8% incidence), including 14 (82%) of 88 patients with CDRIE and 3 (5%) of 59 patients with LDI. Ghosts were never observed among the remaining 65 non infected patients. A significant association was found between CDRIE and the presence of ghost (OR=7.63, 95%; CI 2.12-27.45, p=0.001). At three months, 2 patients with ghost died from sudden death, 2 underwent surgery and one had a pulmonary embolism. Conclusions Ghost is a newly described echocardiographic finding observed after percutaneous device extraction. Its presence is highly suggestive of device infection and might represent a new criterion for the diagnosis of CRDIE. The prognostic significance of such finding needs further investigations.

Economic implications of infections of implantable cardiac devices in a single institution

The use of medical devices, such as cardiac pacemakers, prosthetic heart valves and vascular prostheses, has become a routine treatment procedure in cardiovascular medicine. Unfortunately, bacterial infections of these devices are a serious and sometimes life-threatening for the patient, necessitating explantation. Despite implementing different prophylactic strategies to avoid contamination of the device, infections do occur. This study analysed the additional hospital costs associated with managing cardiac device infections, with special focus on cardiac pacemakers/defibrillators, prosthetic heart valves and vascular prostheses. Out of more than 2000 operations performed in our institution in 2006, we had 462 implantations/replacements of cardiac pacemakers/implantable cardioverter defibrillators (ICDs), 577 valve replacement procedures and 613 vascular operations. Among these, we analysed all patients who received operations because of an infection of their cardiac or vascular device. Our investigations focussed on standard parameters regarding additional hospital costs, including length of stay in hospital, required time in the operating room and time in the intensive care unit. In 2006, we had nine cases (n=9) of prosthetic valve endocarditis in our hospital. The average length of stay in hospital for these patients was 25 days, resulting in euro72096 of additional hospital costs per case. Infection of vascular prostheses (n=6) leads to euro35506 per case and 28 days in the hospital. If an infection of cardiac pacemakers (n=7) does occur, the therapy causes a mean additional hospital cost of euro7091. Cardiac device infections are serious and sometimes life-threatening. Therapy and eradication are difficult and protracted and cause high additional hospital costs. Based on our statistical data and the mean incidence of cardiac device infections, we presume for Germany between euro38 and euro140 million in additional hospital costs per year are incurred by infections of implantable cardiovascular devices. Active surveillance and establishment of a central register with documentation of every implantation and the occurrence of any infection can only realise detailed estimates of the economic damage caused by infection of cardiovascular implants. In consideration of the economic consequences, successful strategies must be developed to reduce the incidence of infections.

Cardiac resynchronization therapy in combination with implantable cardioverter-defibrillator

Device therapy for heart failure has a spectacular development during the last 10 years. Patients with chronic heart failure might benefit from electrical therapy with a view to: (i) resynchronize the failing and dyssynchronized heart and improve its mechanical performance or (ii) prevent the risk of sudden death by automatic defibrillation. These two therapies can be applied together with a combined device, the biventricular implantable cardioverter-defibrillator (CRT-D). Today, the proportion of CRT-D devices among all CRT devices implanted around the world is more than 75% and more than 85% in the USA. This review article will try to answer some important questions for clinical practice: is the growing use of CRT-D devices supported by clinical evidence? Is the risk-benefit profile of CRT-D favourable in particular in mildly symptomatic patients?

STATINS REDUCE APPROPRIATE CARDIOVERTER-DEFIBRILLATOR SHOCKS AND MORTALITY IN PATIENTS WITH HEART FAILURE AND COMBINED CARDIAC RESYNCHRONIZATION THERAPY AND CARDIOVERTER-DEFIBRILLATORS

PURPOSE: To investigate the effect of statins on appropriate cardioverter-defibrillator (CD) shocks and mortality in patients with heart failure treated with combined cardiac resynchronization therapy (CRT) and CDs.

Noncompaction of ventricular myocardium in an elderly woman

Noncompaction of ventricular myocardium (NVM) is classified among genetic cardiomyopathies, and is thought to be caused by failure of the myocardial compaction process during embryogenesis [1]. This leads to a hypertrabeculated left ventricular myocardium with deep intertrabecular recesses that communicate directly with the main ventricular chamber [2]. In this paper, we describe a case of NVM in an elderly patient. A 68-year-old woman was admitted to our Cardiology unit because of worsening dyspnea and peripheral edema. Eight years prior to admission, she had been diagnosed with hypertension and persistent atrial fibrillation, and was placed on warfarin therapy. Five years later, the patient was acutely admitted for dyspnea, and during the stay she had a dysrhythmic syncopal episode. On this occasion, after an extensive diagnostic work-up including coronary angiography, which revealed a normal coronary artery tree, she underwent the implantation of a biventricular pace-maker and cardioverter defibrillator, and was discharged with a diagnosis of dilated cardiomyopathy. At the time of the present admission, the patient was taking warfarin, furosemide 50 mg/day, ramipril 5 mg/day, digoxin 0.125 mg/ day, and bisoprolol 1.25 mg/day. The patient was in NYHA class IV, and on physical examination, she appeared acutely ill. She had a prominent jugular pulse, a holosystolic murmur over the mitral and aortic valves, reduced breath sounds and rales at both pulmonary bases, and peripheral leg edema. The ECG confirmed the presence of atrial fibrillation and left bundle branch block. A chest X-ray study revealed an enlarged cardiac silhouette and hilar congestion. Admission blood analyses were normal except for a plasma cholesterol (267 mg/dl) and pro-BNP (1,463 pg/ml, normal range 0–450). Echocardiographic examination revealed a dilated and globus left ventricle (tele-diastolic diameter 60 mm) with diffuse hypokinesia (ejection fraction 25%), bilateral atrial dilatation, moderate mitral and mild tricuspidal valve insufficiencies with an estimated systolic pulmonary pressure 55 mmHg, and diastolic dysfunction (E/A ratio [ 2). In the lateral wall and apical region, several trabeculations, typical of NVM, were observed (Fig. 1). The ratio between noncompacted and compacted myocardium in telediastole was 2.3. No other valvular abnormalities were observed. After two days of therapy with furosemide 40 mg i.v. bid the clinical condition improved, and the patient’s medications were raised to ramipril to 10 mg/day, bisoprolol to 5 mg/day, and oral furosemide to 100 mg/day, while continuing therapy with warfarin and digoxin, and starting therapy with lovastatin 20 mg/day. The patient was discharged and followed-up for 6 months, and did not experience any further heart failure exacerbations. Her two sons agreed to be examined by echocardiographic screening, and were found to be free of NVM. The NVM is a rare congenital cardiomyopathy, which can be sporadic or familial [2, 3]. Although initially described in children, several case series report this entity to also be present in adults, but rarely, in elderly patients [2–4]. The prevalence of NVM is estimated to range between 0.05% and 0.24% of all echocardiographic investigations in recent studies, while its incidence in the general population is yet unknown [2, 3]. Patients carrying NVM can remain asymptomatic or with only minimal A. Curro A. Lauro R. Gallo A. Corsonello Istituto Nazionale di Ricovero e Cura per Anziani (INRCA), Cosenza, Italy

Idiopathic Left Ventricular Aneurysm Causing Ventricular Tachycardia with 1:1 Ventriculoatrial Conduction and Intermittent Wenckebach Block

Left ventricular aneurysms (LVAs) can be congenital or acquired. They develop most frequently after myocardial infarction. Other causes include hypertrophic cardiomyopathy, arrythmogenic right ventricular cardiomyopathy, myocarditis, chest trauma, sarcoidosis or Chagas disease [1, 2]. LVAs without identifiable cause are considered as idiopathic. Most of LVAs are asymptomatic and are occasionally identified during routine diagnostic procedures. However, in rare cases LVAs may be associated with life-threatening ventricular tachyarrhythmias (mostly ventricular tachycardia, VT) and sudden cardiac death, even as a first manifestation [3]. In most of the cases VT has right bundle branch block morphology consistent with left ventricular origin. Idiopathic LVAs are anatomically distinguished from congenital diverticula, which are characterized by a narrow communication with the ventricle [2, 4]. In this report we describe an interesting and rare case of idiopathic LVA associated with sustained monomorphic VT, ventriculoatrial conduction and intermittent Wenckebach block. Management strategies are discussed and our treatment approach is presented. Case Report A 72-year old woman was admitted to our hospital with palpitations, dizziness and fatigue from a few hours ago. The patient had a history of heart failure (NYHA II) from three years ago and also an episode of paroxysmal atrial flutter two years ago. She was free of angina and had no cardiovascular disease risk factors. The family history was unremarkable with respect to cardiac arrest, unexplained syncope, ventricular tachyarrhythmias, or cardiomyopathy. At the time of presentation to the emergency department the patient was receiving carvedilol, valsartan, and furosemide. The baseline 12-lead ECG revealed a sustained monomorphic VT with RBBB morphology and left axis deviation (Fig. ​1A1A). Since tachycardia was poorly tolerated with systolic blood pressure of 80 mmHg an electrical cardioversion was applied and the rhythm was restored to sinus (Fig. ​1B1B). The ECG, physical examination and laboratory tests after the cardioversion were unremarkable. Fig. (1A) ECG on admission showing the ventriculat tachycardia (VT) with RBBB morphology, (B). Restoration of VT to sinus rhythm with electrical cardioversion, (C). Induced VT with LBBB morphology during the electrophysiology study, (D). Electrogram during the ... The chest X-ray revealed an increased cardiothoracic index. The transthoracic echocardiogram showed dilated left ventricle with a lateral wall aneurysm, left ventricular ejection fraction of 40% and mild mitral regurgitation (Fig. ​2A2A). The coronary angiography revealed normal coronary arteries, whereas the left ventriculography further confirmed the lateral wall aneurysm (Fig. ​2B2B). Magnetic resonance imaging further confirmed the presence of the LVA (Fig. ​2C2C). Fig. (2A) Echocardiogram showing the left ventricular aneurysm (arrows), (B). Left ventriculography further depicting the lateral wall aneurysm (arrows), (C). Magnetic resonance imaging further confirmed the presence of an aneurysm with wall thinning (arrows). The patient was started on amiodarone per os and after two weeks an electrophysiology study was performed. The programmed ventricular stimulation in the right ventricular apex with 500/230-240 msec basic drive cycle and two extrastimuli reproducibly induced sustained monomorphic VT of 160 bpm associated with hemodynamic instability. That tachycardia, however, had different characteristics from the one at the emergency department as it was associated with left branch bundle block (LBBB) morphology and normal cardiac axis and was terminated by overdrive pacing (Fig. ​1C1C). The LBBB morphology was consistent with septal origin of the VT. Of note, during the inducible VT a 1:1 ventriculoatrial conduction with intermittent Wenckebach block was recorded (Fig. ​1D1D). A cardioverter defibrillator (ICD) was implanted for the secondary prevention of VT and the patient was discharged 2 days after ICD implantation on treatment with carvedilol, amiodarone and angiotensin converting enzyme inhibitor. During a follow-up period of six months no ventricular arrhythmias occurred.

Continue or withhold oral anticoagulation in high-risk patients undergoing pacemaker or ICD implantation

Tolosana et al. have reported the results of a randomized study, which compared two procedures in preparation for implantation of pacemakers or cardioverter defibrillators (ICDs) in a small population of chronically anticoagulated patients at high risk of thrombo-embolic events.1 One group was randomly assigned to continued oral anticoagulation (OAC) reduced to a target international normalized ratio (INR) near 2.0 for the procedure, and the other to temporary replacement of OAC by heparin, as recommended by current guidelines for high-risk patients.2–4 Considering the high proportion of chronically anticoagulated patients among the large population of cardiac device recipients, this is an important issue. In the recently published French PEOPLE registry,5 11% of patients remained on OAC and nearly 20% received heparin at the time of procedure. This patient population is exposed to a dual risk during the critical period of re-arrangement of anticoagulation: (i) haemorrhage, particularly procedure-related pocket haematoma; and (ii) thrombo-embolism from under-anticoagulation during the peri-operative period. Furthermore, the choice of anticoagulation strategy directly influences the duration of hospitalization and overall cost of treatment. Except in special cases, OAC should not be withheld for minor procedures associated with a low risk of haemorrhage. In the presence of mechanical valve prostheses, it is currently recommended to continue OAC with an INR near 2.0.3 The implantation of cardiac devices is associated with an intermediate risk of local haemorrhage, which complicates procedures performed during full anticoagulation. The risk of pocket haematoma after pacemaker or ICD implantation under anticoagulation varies between 20 and 25% among past and recent studies including small numbers of patients,7 though it was lower in recently published, large, prospective single- or multicentre registries.4,8 Wiegand et al. found a 4.9% overall risk of pocket haematoma after 3164 pacemaker or ICD implantations, which … *Corresponding author: Tel: +33 299 282 525, Fax: +33 299 282 510, Email: jean-claude.daubert{at}chu-rennes.fr

A simplified biventricular defibrillator with fixed long detection intervals reduces implantable cardioverter defibrillator (ICD) interventions and heart failure hospitalizations in patients with non-ischaemic cardiomyopathy implanted for primary prevention: the RELEVANT [Role of long dEtection window programming in patients with LEft VentriculAr dysfunction, Non-ischemic eTiology in primary prevention treated with a biventricular ICD] study

AimsTo investigate the efficacy and safety of a cardiac resynchronization therapy with cardioverter–defibrillator (CRT-D) device with simplified ventricular tachycardia management in patients with non-ischaemic heart failure (HF) and primary prevention implantable cardioverter defibrillator (ICD) indication.Methods and resultsProspective, controlled, parallel, multicentre, non-randomized study enrolling 324 primary prevention non-ischaemic HF patients implanted with CRT-D devices from 2004 to 2007: Protect group, 164 patients implanted with a Medtronic Insync III Protect device and Control group, 160 patients utilizing other Medtronic CRT-D devices.Efficacy was assessed by computing appropriate and inappropriate detections and therapies during follow-up; safety compared hospitalizations and syncopal events between groups. Ninety per cent of both ventricular and supraventricular tachyarrhythmias terminated within the 13–29 beat detection interval with the Protect algorithm. The Protect group showed a significantly better event-free survival to first delivered therapy for total (P = 0.0001), appropriately treated (P = 0.002), and inappropriately treated episodes (P = 0.017). The total number of delivered shocks was significantly lower in the Protect group (22 vs. 59, P < 0.0001). In the Protect group, a significantly reduced HF hospitalization (hazard ratio 0.38, 95% CI 0.15–0.98, P = 0.044) was observed without any increase of syncope or death.ConclusionA simplified CRT-D device with fixed long detection reduced overall ICD therapy burden and HF hospitalizations without entailing any additional adverse events in primary prevention non-ischaemic HF patients.

Hypertrophic cardiomyopathy with midventricular obstruction and apical aneurysm formation in a single family: case report

BackgroundHypertrophic cardiomyopathy (HCM) is an extremely heterogeneous disease. An under recognized and very often missed subgroup within this broad spectrum concerns patients with left ventricular (LV) apical aneurysms in the absence of coronary artery disease.Case presentationWe describe a case of HCM with midventricular obstruction and apical aneurysm formation in 3 patients coming from a single family. This HCM pattern was detected by 2D-echocardiography and confirmed by cardiac magnetic resonance imaging. A cardioverter defibrillator was implanted in one of the patients because of non-sustained ventricular tachycardia detected in 24-h Holter monitoring and an abrupt drop in systolic blood pressure during maximal exercise test. The defibrillator activated 8 months after implantation by suppression of a ventricular tachycardia providing anti-tachycardia pacing. The patient died due to refractory heart failure 2 years after initial evaluation. The rest of the patients are stable after a 2.5-y follow-up period.ConclusionThe detection of apical aneurysm by echocardiography in HCM patients may be complicated. Ventricular tachycardia arising from the scarred aneurysm wall may often occur predisposing to sudden death.

Fourteen-Year Follow-up in a Teenager with Congenital Long QT Syndrome Masquerading as Idiopathic Generalized Epilepsy

Long QT syndrome is a potentially lethal cardiac channelopathy that can be mistaken for epilepsy in young people. We report a 17-year-old man who was initially treated as having both daytime and nocturnal idiopathic epilepsy for 5 years. A series of electrocardiograms showed the time of the convulsive episodes, and genetic testing lead to the final diagnosis. The combined use of a beta-blocker and a pacemaker implant incompletely abolished the torsade de pointes. After an additional near-fatal event, a cardioverter defibrillator was implanted as final bridge therapy. An electrocardiogram with the correct calculation of the QT interval should be performed on all young people with a suggestive history; that is, treat refractory convulsive episodes specifically with nondiagnostic electroencephalograms.

Inappropriate shock from nonphysiologic noise during implantation of a Boston Scientific COGNIS N119 biventricular implantable cardioverter-defibrillator (CRT-D)

Noise, often visible on the intracardiac electrogram (EGM), may affect sensing and result in inappropriate therapy in implanted cardiac rhythm management devices. We present a case of inappropriate shock from an uncommon cause of nonphysiologic noise during implantation of a Boston Scientific COGNIS N119 cardiac resynchronization therapy defibrillator (CRT-D).

The ABCD (Alternans Before Cardioverter Defibrillator) Trial: Strategies Using T-Wave Alternans to Improve Efficiency of Sudden Cardiac Death Prevention

Because risk stratification with electrophysiological study (EPS) improves efficiency but is invasive, we sought to determine whether noninvasive microvolt T-wave alternans (MTWA) testing could identify patients who benefit from implantable cardioverter-defibrillators (ICDs) as well as EPS. Prevention of sudden cardiac death on the basis of left ventricular ejection fraction (LVEF) alone is inefficient, because most ICDs never deliver therapy. The ABCD (Alternans Before Cardioverter Defibrillator) trial is a multicenter prospective study that enrolled patients with ischemic cardiomyopathy (LVEF < or =0.40) and nonsustained ventricular tachycardia. All patients underwent MTWA and EPS. ICDs were mandated if either test was positive. Of 566 patients followed for a median of 1.9 years, 39 (7.5%) met the primary end point of appropriate ICD discharge or sudden death at 1 year. As hypothesized, primary analysis showed that MTWA achieved 1-year positive (9%) and negative (95%) predictive values that were comparable to EPS (11% and 95%, respectively). In addition, secondary analysis showed that at the pre-specified 1-year end point, event rates were significantly higher in patients with both a positive MTWA-directed strategy (hazard ratio: 2.1, p = 0.03) and a positive EPS-directed strategy (hazard ratio: 2.4, p = 0.007). Moreover, the event rate in patients with both negative MTWA test and EPS was lower than in those with 2 positive tests (2% vs. 12%; p = 0.017). The ABCD study is the first trial to use MTWA to guide prophylactic ICD insertion. Risk stratification strategies using noninvasive MTWA versus invasive EPS are comparable at 1 year and complementary when applied in combination. Strategies employing MTWA, EPS, or both might identify subsets of patients least likely to benefit from ICD insertion. (Study to Compare TWA Test and EPS Test for Predicting Patients at Risk for Life-Threatening Heart Rhythms [ABCD Study]; NCT00187291).

Empfehlungen zur Strukturierung der Herzschrittmacher- und Defibrillatortherapie

Therapy with implantable pacemakers, cardioverter defibrillators (ICD), and devices for cardiac resynchronization (CRT) is performed by various medical and surgical specialists. With the change from implantation by thoracotomy to the transvenous approach, an increasing number of devices are implanted by cardiologists. The purpose of this paper is to establish training requirements for transvenous device therapy, implantation and follow-up examinations, regardless of the implanting person, an internist, cardiologist, general surgeon, or cardiothoracic surgeon. Epicardial lead placement should be performed only by surgeons. Two levels of training topics are defined, level 1 for pacemakers and level 2 for ICD and CRT devices. Surgery that involves the implantation of foreign material should demand the highest standards of operating rooms design and environment. Catheter laboratories used for implantations should meet operating room standards. Complications need to be documented carefully for quality control.

Transpulmonary thermodilution and pulse pressure variations in a septic patient with heterotopic cardiac transplantation

55-year-old man was admitted to the inten-sive care unit for shock. He had a history ofsevere coronary artery disease and arterialhypertension, and had undergone heterotopic car-diac transplantation 14 years ago for refractive con-gestive heart failure. Persistent ventricular arrhyth-mia attributed to native heart dysfunction wasinitially treated medically. A cardioverter defibril-lator was implanted after recurrence of syncopalventricular tachycardia 2 years ago. On admission,severe hypotension was noted (73/53 mm Hg).Physical examination at the time of admissionshowed no cardiac murmur or abnormal heartsounds. The patient’s heart rate was 90 beats/minand temperature was 38.6°C. Mechanical ventilation(controlled mode, tidal volume 9 mL/kg, respiratoryrate 20 breaths/min, F

Pressure-volume loop analysis during implantation of biventricular pacemaker/cardiac resynchronization therapy device to optimize right and left ventricular pacing sites

To evaluate the clinical utility of pressure-volume loop analyses during pacemaker/implantable cardioverter defibrillator (ICD) implantations to assess the optimal right ventricular (RV) and/or left ventricular (LV) lead position. 29 patients with heart failure and chronic RV apical pacing were studied. Stroke work (SW), LV ejection fraction (LVEF), cardiac output (CO), and LV dP/dt(max) were assessed using a conductance catheter in the LV during RV apical, RV outflow tract, single-site LV, and biventricular pacing at different left-sided pacing locations. Left ventricular ejection fraction was 34.3 +/- 9.8%. Compared with baseline, RV outflow tract pacing showed a small increase of 4.0 +/- 6.4% in LV dP/dt(max) and no improvement in SW, LVEF, or CO. In the optimal biventricular configuration, SW increased 39 +/- 41%, LVEF increased 22 +/- 13%, CO increased 16 +/- 16%, and LV dP/dt(max) increased 10 +/- 11% (all P < 0.05). In 45% of the patients, the optimal LV lead position was found at a different location as the 'first choice' postero-lateral or lateral target vein. Pressure-volume loop analysis during pacemaker/ICD implantations facilitates to determine the optimal LV pacing site. Patients with chronic RV pacing showed a significant acute improvement in LV function when LV pacing or biventricular pacing is applied.

Comparison of single and double vein approaches for His bundle ablation and pacemaker placement for symptomatic rapid atrial fibrillation

His Bundle ablation (HBA) with permanent pacemaker (PPM) implantation is an effective strategy for controlling heart rate in symptomatic patients with rapid atrial fibrillation (AF), resistant to pharmacologic therapy. The standard double vein (DV) approach involves mapping and HBA from a femoral approach to achieve complete heart block (CHB), while single chamber (SC), dual chamber (DC), or biventricular (BiV) PPM is then placed via a subclavian approach. We compared 7 patients with drug-resistant rapid AF who underwent the standard DV approach to 8 patients who underwent a single vein (SV) approach, in which HBA and PPM implantation were performed through the subclavian vein. The two groups were compared for acute success in creating CHB, total procedure and fluoroscopy times and patient discomfort. Results are expressed as mean +/- standard error (SEM). The procedure times for the SV versus DV were 70.4 +/- 11.4 v 100.0 +/- 19.2 min, and the fluoroscopy times, 13.9 +/- 3.1 (SV) v 13.0 +/- 2.9 (DV). All patients were discharged in stable condition with CHB and SC, DC pacemaker or BiV/Implantable Cardioverter Defibrillator (ICD). CHB with symptomatic improvement was maintained in all patients over a mean follow-up period of 22.6 months (SV), and 9.6 months (DV). The SV approach for HBA combined with PPM implantation was at least as effective and may be more efficient than the classic DV approach, and should be considered as an alternative to DV technique to reduce procedural time and patient discomfort.

Abstract 2006: Contrast-Enhanced MRI in the Hyperacute Phase of ST-Elevation Myocardial Infarction Predicts Late Myocardial Recovery

Left ventricular ejection fraction (EF) late after myocardial infarction determines whether patients will benefit from cardioverter/defibrillator (CV/D) implantation. At present, patients with acute ST elevation myocardial infarction (STEMI) are evaluated several months later to determine EF and CV/D indication following initial recovery. We determined whether contrast-enhanced MRI (CE-MRI) in the hyperacute phase of STEMI could predict late myocardial recovery. 50 patients with STEMI underwent CE-CMR within 12 hours of primary angioplasty (median 4h). All had follow-up CE-CMR &gt;6 months later. Global and segmental left ventricular function, morphology, perfusion and necrosis were determined and assessed by validated techniques (QMass, Medis, the Netherlands). In the hyperacute phase of STEMI, a greater cardiac output (4.2 vs 3.4 L/min, p=0.01) was measured due to significantly greater heart rate (72 vs 57 bpm, p&lt;0.01) despite similar stroke volumes (59 vs 60mL, p=NS) compared to &gt;6 months later. On average, LVEF did not significantly change from hyperacute STEMI to recovered phase (51 vs 54%, p=NS) but systolic wall thickening increased on average from 41 to 50% (p=0.01) due to compensatory increased systolic thickening of non-infarct related segments. LV mass decreased from 120 to 105 g (p=0.01) due to a decrease in mean wall thickness driven by infarct segment wall thinning (9.2 vs 8.4mm, p&lt;0.01). Microvascular function improved significantly (time to 50% enhancement on first-pass CE-MRI: 24.3 vs 21.7ms, p=0.03). Contrary to prior reports of “scar shrinkage” comparing necrosis in the first week after STEMI and 6 months later, necrosis relative to total myocardial volume did not differ between the hyperacute phase and &gt;6 months (20 vs 18%, p=0.46). Furthermore, the transmural extent of necrosis, a potent predictor of functional recovery, did not significantly change from the hyperacute to the recovered phase of STEMI (mean 17 vs 14%, p=0.38). CE-MRI in the hyperacute phase of STEMI is a powerful predictor of long-term myocardial function and necrosis which could prove useful for very early risk stratification and future targeting of appropriate therapies.

Heart Rhythm Society Policy Statement Update: Recommendations on the Role of Industry Employed Allied Professionals (IEAPs)

R ntroduction n 2001, the North American Society of Pacing and Elecrophysiology (Heart Rhythm Society) published a policy tatement to provide guidance for industry employed allied rofessionals (IEAPs) who render technical assistance durng pacemaker/Implantable Cardioverter Defibrillator (ICD) mplantations, programming, analysis of malfunctions, and ollow-up. These principles were incorporated in a recent onsensus document on the monitoring of implanted cariovascular electronic devices. The term IEAP is applied o persons who are employed or contracted manufacturer epresentatives, field clinical engineers, and industry emloyed technical specialists. These individuals often have xpertise about specific features of pacemakers or ICDs that s unique to the manufacturer’s product. This expertise may e extremely valuable to physicians and the clinical allied rofessionals (CAPs) they employ. In some instances, CAPs ay be employed by the institution incident to the practice f the responsible physician. The physician bears the reponsibility for assessing effectiveness of device programing and any device malfunctions and recommending speific courses of action. The Heart Rhythm Society sponsored an Industry Forum n July 2007 to discuss the role of industry in the care of atients with heart rhythm disorders. One topic of discusion was the role of IEAPs and the need to update the uidelines published in 2001. The meeting was attended by enior Heart Rhythm Society (HRS) staff, officers of HRS, nd executives representing several leading manufacturers f technology used in the care of heart rhythm disorders. broader scope of devices is in widespread use today. lthough pacemakers and ICDs remain central to this disussion, the guidelines must also account for technical asistance supporting intra-cardiac echocardiography, electronatomic mapping systems, remote navigation, and other echnologies that are evolving to assist complex procedures

Electrical storm in patients with biventricular implantable cardioverter defibrillator: Incidence, predictors, and prognostic implications

The aim of the present study was to evaluate the incidence, predictors, and related outcomes of patients with heart failure (HF) treated with cardiac resynchronization therapy with an implantable cardioverter defibrillator (CRT-D) who experienced electrical storm (ES). Electrical storm was defined as the occurrence of >or=3 episodes in 24 hours of sustained ventricular tachyarrhythmias. A total of 631 patients with HF (90% male, mean 66+/-9 years) consecutively received a CRT-D device. At baseline, the mean left ventricular ejection fraction was 26%+/-7%, the QRS duration was 164+/-33 milliseconds, and the mean New York Heart Association class was 3.3+/-0.3. During a mean follow-up of 19+/-11 months, 2,419 ventricular tachyarrhythmia episodes were appropriately detected in 141 (22%) patients. Electrical storm occurred in 45 (7%) of 631 patients. Kaplan-Meier analysis and multivariable Cox regression showed that ES is more frequent in secondary prevention (hazard ratio 2.3, 95% CI 1.2-4.3, P=.015) and in nonischemic patients (hazard ratio 2.0, 95% CI 1.1-3.8, P=.028). In patients who presented ES, CRT was associated with only marginal nonsignificant improvements of New York Heart Association class and left ventricular ejection fraction. Hospitalizations and death due to HF were more frequent in patients with ES compared with those without ES, amounting to 16.8 (4.3) versus 8.6 (0.9) per 100 patient-years (P = .018) and 7.7 versus 2.7 per 100 patient-years (P=.014), respectively. Electrical storm affect only 7% of CRT-D recipients and occurred more frequently in nonischemic patients with HF with biventricular implantable cardioverter defibrillators implanted for secondary prevention. Electrical storm was associated with worse HF morbidity and mortality.

Brugada syndrome during physical therapy: a case report

This case report describes about a young, male patient with persisting syncope during physical therapy for complex regional pain syndrome type 1 after metatarsal fractures.The patient was referred to the Emergency Department, where Brugada syndrome was diagnosed. A cardioverter defibrillator was prophylactically implanted successfully. After this procedure, there were no contraindications for resuming further physical therapy for his painful foot. No clear causal inference with Brugada could be drawn from the complex regional pain syndrome type 1 or physical therapy described in this case report. Hyperthermia may, however, occur during such therapy, which is associated with dysrhythmia in general.